Therapy Schedule Now / Patient Registration

Before we can schedule your first appointment, we need some information.
Are you a new patient? *

Yes No
Are you 18 years of age or older? *

Yes No
All Mindful Care therapy services are currently for ages 18 and up.
Legal Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
State *

New York New Jersey Illinois Florida Connecticut
Preferred Appointment Date: *

Month Day Year
Date
Gender *

Male Female Other Non-binary Transgender M2F Transgender F2M Prefer not to say
What are your preferred pronouns? *

He/Him She/Her They/Them
Date of Birth *

Month Day Year
Date
Are you using Insurance for this visit? *

Yes No
Insurance Information
Insurance Provider? *

1199 SEIU Aetna Blue Cross Blue Shield Cigna HealthFirst Humana Medicare Optum Oscar Oxford Health Plan UMR United Behavioral Health United Healthcare Other
Before we can schedule your appointment, we will need a photo of the insurance card you would like to use.

You can either upload those now or at a later time.
Would you like to: *

Upload Now Upload Later
Please upload the FRONT of your insurance card: *

Cancel of
Please upload the BACK of your insurance card: *

Cancel of
Payment Information
I hereby authorize Mindful Care to securely store my credit card and/or other payment details, and charge it when my co-payment and/or deductible is due upon check-in or should I have an outstanding balance or any leftover balance from a processed claim in the future. *

I acknowledge
Signature *

Clear
You indicated that you would like to upload your insurance and payment information at a later time.

Once you complete this form you will receive an email with a link to upload your information when you are ready.

Please be aware that in order to finalize your appointment this information has to be submitted.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Do you have a different mailing address? *

Yes No
Mail Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency contact *

First Name Last Name
Emergency Contact Phone number *
How did you hear about us? *
Name of Therapist or Doctor? *
Do you have a Primary Care Physician?

Yes No
Primary Care Physician
Primary Care Physician Phone
Pharmacy Name / Pharmacy Address
Pharmacy Zip Code
Pharmacy Phone
Patient Health Information
What is the reason for your visit? *
Are you seeking help with us to avoid an ER visit for your mental health needs? *

Yes No
Are your symptoms directly related to the COVID-19 pandemic? *

Yes No
Have you seen a Psychiatrist, Psychologist, or Therapist in the past? *

Yes No
If So When?

Month Day Year
Date
Past Psychiatric History - Check All That Apply *

None ADHD Anger/Outbursts Anxiety Bipolar Disorder Depression Eating Disorder Phobia(s) Obsessive Compulsive Disorder (OCD) Pre-Menstrual Dysphoric Disorder (PMDD) Post Traumatic Stress Disorder (PTSD) Schizophrenia Schizoaffective Disorder Suicide Attempt(s) Panic Disorder Alcohol Abuse Opioid Abuse Self-Harm Visit the Emergency Department for mental health concern Hospitalized for mental health concern Attended facility for substance use disorder Family History of mental illness Other Substance Use
Are you currently taking any psychiatric medications? *

Yes No
Please list the medications you are taking and their doses *
Do you have any drug/medication allergies? *

Yes No
Please list drug/medication allergies:
Are you currently using any of the following substances? (Check all that apply). *

Nicotine Cannabis Opiates/Opioids/Heroin Cocaine Amphetamines Alcohol None of the above
Are You Currently taking any of the following medications? *

SSRI SNRI Tricyclics/TCA Other Antidepressants Mood Stabilizers Antipsychotic mood stabilizers Sleeping pills Anti-anxiety medicines ADHD medicines I am not taking any of the medications listed above Other
Family History - Check All That Apply *

ADHD Alcohol Abuse Anemia Anger/ Outbursts Anxiety Bipolar Disorder Chronic Fatigue Chronic Pain Depression Diabetes Drug Addiction Eating Disorder Epilepsy/Seizures Fibromyalgia Heart Disease High Blood Pressure High Cholesterol Kidney Disease No known Family History
Medical History - Check All That Apply *

Anemia Asthma Cancer Chronic Fatigue Diabetes Endocrine disorders (i.e. thyroid, pancreas, PCOS etc) Epilepsy/Seizures Fibromyalgia Heart Disease High Blood Pressure High Cholesterol HIV Inflammatory Bowel Disease (IBD) Irritable Bowel Syndrome (IBS) Kidney Disease Liver Disease Migraines Multiple Sclerosis Skin condition (i.e. psoriasis, eczema) Stroke Traumatic Brain Injury (TBI) None of the above apply Other
Are you taking any other medications? *

Yes No
Please list the medications you are taking and their doses, including vitamins and herbal supplements. *
What services are you interested in exploring? Check all that apply. *

Psychiatric Services (Medication Management) - Ages 12+ Therapy Services (Individual and Group Therapy) - Ages 18+ Substance Use Counseling - Ages 18+
Mindful Care has a commitment to prescribing medications safely. We do not prescribe any controlled substances, habit-forming medications, or long-acting injectables, with the exception of buprenorphine for those receiving services from Mindful Recovery. We do offer safer alternatives that can be reviewed at your visit. You can read more here: https://mindful.care/controlled-substance-alternatives/ *

I acknowledge
Mindful Care Policies:
https://mindful.care/policies

I acknowledge that I have reviewed all of Mindful Care's treatment and billing policies linked to above and agree to be seen under those policies.
Acknowledgment of Policies *

I acknowledge
Adult Patient Consent to Care (18 years of age or greater)

I hereby authorize Mindful Care by and through its licensed medical professionals to provide me with mental health care services that such professionals deem necessary for diagnosing and/or treating my mental health condition(s). I hereby understand and agree that my sessions with Mindful’s mental health professionals may involve in-depth questions of a sensitive and personal nature including but not limited to such topics as (my history of diagnosed and/or undiagnosed mental health disorders and that of my family members, eating disorders, sexual history and/or abuse, history of suicidal and other self-harm tendencies and events, legal history/ history of interactions with law enforcement authorities, and substance use). I acknowledge and agree that if I am uncomfortable with the treatment outlined or line of questioning engaged in during my Mindful care session that I shall immediately notify my Mindful provider of such, so an alternative treatment regime may be utilized for my benefit. I acknowledge and agree that no guarantees and/ or assurances of any kind have been given to me concerning the results of Mindful’s mental health services including but not limited to the prospective improvement and/or resolution of my present mental health condition. I acknowledge and agree that I have been given the opportunity to ask questions concerning my pursuit of care with Mindful, and that all my questions have been answered to my satisfaction and that I am electing to pursue care with Mindful entirely of my own volition. My signature below indicates that I have fully read and agree to the aforementioned terms.
Acknowledgment of Consent *

I acknowledge
Patient Signature *

Clear
Today's Date *

Month Day Year
Date
Should be Empty:

Insurance Information

Payment Information

Patient Health Information